Provider Demographics
NPI:1811417140
Name:BLANKENSHIP, AMY (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 MCARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5511
Mailing Address - Country:US
Mailing Address - Phone:618-462-0634
Mailing Address - Fax:
Practice Address - Street 1:3512 MCARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5511
Practice Address - Country:US
Practice Address - Phone:618-462-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.004773101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional